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Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

Report Information

Issue Date
Report Number
16-00107-256
VISN
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 114 employees. This review focused on eight operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the computed tomography radiation monitoring activity. The facility’s reported accomplishment was receiving a Certificate of Recognition from Dr. Shulkin, the VA Under Secretary for Health, for its polytrauma programs. OIG made recommendations for improvement in the following eight activities, which includes the follow-up review area: (1) quality, safety, and value; (2) environment of care; (3) medication management; (4) coordination of care; (5) advance directives; (6) suicide prevention program; (7) mammography services; and (8) follow-up on medication management – controlled substances inspection program.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove outdated commercial supplies from patient care areas and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure operating rooms are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged furniture in the operating rooms.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the compounded sterile products safety policy to include verification of all finished compounded sterile products by a pharmacist.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document cleaning of storage shelving and bins in all compounding areas and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide discharge instructions to patients and/or caregivers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a plan for transition to the allowed note titles.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees use the required advance directive note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the mammography services policy includes all required elements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Controlled Substances Coordinator ensure all required non-pharmacy areas with controlled substances are inspected and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility strengthen processes to ensure weekly inventories of automated dispensing machines are consistently conducted and that facility managers monitor compliance.